2010 UBO/UBU Conference

Health Budgets & Financial Policy

Briefing: Cosmetic Surgery Policy Challenges for the Billing Office

Date: 23 March 2010

Time: 1510–1600

2010 UBO/UBU ConferenceTurning Knowledge Into Action Objectives

Overview of Cosmetic Surgery MSA business processes Analyze and prioritize risk areas Develop a plan to monitor and close risk exposures Discuss effective communication when interacting with

other stakeholders Share Best Practices from the field

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2010 UBO/UBU ConferenceTurning Knowledge Into Action

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Organizational resources available– TMA User Guide – Process Flow chart – Service guidance – Internal policies and established procedures

Divide entire business and revenue cycle into three parts – Pre-procedural processes – Post-procedural reconciliation and billing – Annual updates including resource distribution and training

Determine internal resources available and then prioritize – Inadequate staffing often cited as a barrier – Experience and authority of MSA staff has an impact – Know what you can control and what you can’t – How do you identify and prioritize to improve your processes?

Overview of MSA Business Cycle Processes

2010 UBO/UBU ConferenceTurning Knowledge Into Action Identify Risks in the Business Cycle

Use the Process Overview from the User Guide to start – Categorize distinct activities in your business cycle

Pre-procedure, Reconciliation, Annual, for example

– Determine primary stakeholder and other participants– Identify risk areas by asking yourself what could go wrong with

each activity – List risk factor flags by reviewing each step, looking for gaps that

may not be defensible if someone says “What if...?”

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Risk Area Determine Risk Factor Flags

Business Cycle Category

Stakeholders – Primary Listed First

2010 UBO/UBU ConferenceTurning Knowledge Into Action Analyze and Prioritize Risk Areas

Now that the risks are identified, map out the results to develop a plan

– Some risks are intertwined, and addressing them all at the same time can be overwhelming

– Target each component of the overall assessment methodically – You’ll know what’s being done well and which need attention – Quantify the risk by stratifying then prioritize

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Risk Level – $ Finance

Risk Level – Bus Ops

Control Factor – Bus Ops Complaint

Level of Effort – Bus

Priority Ranking

2010 UBO/UBU ConferenceTurning Knowledge Into Action Take Action With a Gap Closure Plan

This is not a one-person undertaking – it takes a team! – Start within your department;1-2 people develop

framework – Team meeting(s) to add detail and prioritize

implementation– Great start to developing a comprehensive compliance

plan Tickler files, whether manual or electronic, or both, are great

gap closers Implement “quick hitters” to start out

– Known factors, like staffing issues, can change risk priority Provides a great starting point for strengthening

communication with other stakeholders in your facility

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Interaction with Other Stakeholders

One last area that is likely a frustration

MSA staff are integral to Cosmetic Surgery policy compliance

– But not intended to be the policing authority

Clinical interpretation of what is cosmetic vs. medically necessary or reconstructive surgery varies across the enterprise

Refer policy questions related to clinical justification through the MTF and/or Service organizational chain

Elevate policy questions via UBO Helpdesk for assistance to support MHS Enterprise consistency with Cosmetic Surgery policy compliance

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2010 UBO/UBU ConferenceTurning Knowledge Into Action Helpdesk Assistance & Resources

UBO.Helpdesk@altarum.org– Include “Cosmetic Surgery” or “CS” in subject line– Queries that are policy centric (e.g., physician requests, pricing

exceptions, medical necessity clarification) will be elevated to the UBO Program Manager and Deputy Program Manager for coordinated response – a ticket will be opened and tracked

– You should cc your Service Manager on Helpdesk questions– Technical issues like download issues or program navigation

challenges are responded to quickly– Together with the strong MSA staff and leadership across the

MHS enterprise, we will continue to “define and refine”

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2010 UBO/UBU ConferenceTurning Knowledge Into Action

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Sharing Best Practices from the Field

Courtesy of MSA Business Office at Madigan AMC Cosmetic Surgery Tracking Tool

Patient Name Clinic PhysicianMainProcedure

DateReceived

TotalAmount

Date Faxedto Clinic

DOE, JANE PLASTIC DR. BOB LIPOSUCTION 13-Jul-09 $2,580.00 14-Jul-09

DOE, JANE PLASTIC DR. BOB MAMMAPLASTY 9-Jul-09 $8,060.00 10-Jul-09

DOE, JANE VASCULAR DR. CAT SCLEROTHERAPY 10-Jul-09 $150.00 WINDOW

DOE, JANE VASCULAR DR. CAT SCLEROTHERAPY 14-Jul-09 $160.00 WINDOW

DOE, JANE PLASTIC DR. SHOE MAMMAPLASTY 9-Jul-09 $8,060.00 10-Jul-09

DOE, JANE PLASTIC DR. SHOE ABDOMINOPLASTY 13-Jul-09 $4,580.00 14-Jul-09

DOE, JANE PLASTIC DR. DOOR MAMMAPLASTY 9-Jul-09 $8,060.00 10-Jul-09

OUT TO CODI NG

PATI ENT PAI D

(NO COLOR)Esti mates Faxed to Cl i ni c

RM PAI D CLI NI C/ TRANSFERRED

2010 UBO/UBU ConferenceTurning Knowledge Into Action Sharing Best Practices, Cont’d

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Cosmeti c Surgery Tracki ng Tool

DatePaid

Date ofSurgery

Date toCoding

Date ReturnedFrom Coding Refund

RMMESSAGE

AMOUNT PAIDCLINIC

20-Jul-09 22-Jul-09 30-Jul-09 4-Aug-09 OK TO PAY $2,580.00

10-Jul-09 TBD

14-Jul-09 TBD

11-Jul-09 $8,060.00 CHANGED MIND

15-Jul-09 6-Aug-09 15-Aug-09

OUT TO CODI NG

PATI ENT PAI D

2010 UBO/UBU ConferenceTurning Knowledge Into Action Questions / Answers / Discussion?

Goal Setting Best Practices Communication Is Key

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Thank you for your help. I appreciate it!